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Hypertension (2012) Philippine Society of Hypertension Unit 309 Amberland Plaza, Julia Vargas St., Ortigas Complex, Pasig Telephone Nos.: 631-7970; 687-7073; 687-2841 Fax No.: 631-7970 E-mail: [email protected] Website: http://www.psh.org.ph Hypertension Philippine Society of Hypertension Unit 309 Amberland Plaza, Julia Vargas St., Ortigas Complex, Pasig Telephone Nos.: 631-7970; 687-7073; 687-2841 Fax No.: 631-7970 E-mail: [email protected] Website: http://www.psh.org.ph Officers and Board of Trustees 2011-2013 President Vice President Secretary Treasurer Trustees Immediate Past President Dante D. Morales, M.D Romeo A. Divinagracia, M.D. Lynn A. Gomez, M.D. Vicente V. Tanseco, Jr., M.D. Leilani B. Mercado-Asis, M.D. Eugenio Jose F. Ramos, M.D. Alberto A. Atilano, M.D. Abdias V. Aquino, M.D. www.TheFilipinoDoctor.com l Sign up and open your clinic to the world. 141 Hypertension PHILIPPINE CLINICAL PRACTICE GUIDELINES ON THE DETECTION AND MANAGEMENT OF HYPERTENSION – 2011 (also known as the 140/90 Report) NELSON S. ABELARDO, MD, FPCP, FPCC For the Multisectoral Task Force Consensus on the Detection and Management of Hypertension in the Philippines DISCLAIMER: The recommendations contained in this report are intended to GUIDE practitioners in the detection and management of hypertension in adult patients. In no way should the guidelines be regarded as ABSOLUTE RULES, since nuances and peculiarities in individual cases or particular communities may entail specific approaches. In the end, the recommendations should supplement, and not replace sound clinical judgment. 142 Hypertension The Multisectoral Task Force Consensus on the Detection and Management of Hypertension in the Philippines Chair : Dr. Nelson S. Abelardo Members: Dr. Adoracion N. Abad Dr. Mary Ann Lim VA Abrahan Dr. Ramon F. Abarquez Jr. Dr. Abdias V. Aquino Dr. Joselito L. Atabug Dr. Alberto A. Atilano Dr. Esperanza I. Cabral Dr. Eduardo Vicente S. Caguioa Dr. Homobono B. Calleja Dr. Rafael R. Castillo Dr. Antonio Miguel L. Dans Dr. Romeo A. Divinagracia Dr. Bun Yok O. Dy Dr. Ruby T. Go Dr. Lynn A. Gomez Dr. Raul D. Jara Dr. Ruby G. Lim Dr. Agnes D. Mejia Dr. Leilani B. Mercado-Asis Dr. Dante D. Morales Dr. Deborah D. Ona Dr. Elizabeth Paz-Pacheco Dr. Gregorio B. Patacsil Jr.+ Dr. Felix Eduardo R. Punzalan Dr. Eugenio Jose F. Ramos Dr. Eugenio B. Reyes Dr. Vicente V. Tanseco Jr. Dr. Tommy Ty Willing Dr. Norbert Lingling D. Uy Dr. Rody G. Sy Dr. Antonio S. Sibulo Jr. Dr. Jorge A. Sison Dr. Wilson L. Tan- De Guzman Dr. Emma G. Trinidad Dr. Milagros E. Yamamoto Partner Agencies or Coordinating Committee Member Organizations •Department of Health (DOH) •Philippine Medical Association (PMA) •Philippine College of Physicians (PCP) •Philippine Heart Association (PHA) •Philippine Lipid and Atherosclerosis Society (PLAS) •Philippine Society of Endocrinology and Metabolism (PSEM) •Diabetes Philippine •Stroke Society of the Philippines (SSP) •Philippine Society of Nephrology (PSN) •Philippine Neurological Association (PNA) •Philippine Society of Vascular Surgery (PSVS) •Philippine Academy of Family Physicians (PAFP) •Philippine Association of Military Surgeons (PAMS) •Philippine College of Occupational Medicine (PCOM) •Philippine Association for the Study of Overweight and Obesity (PASOO) •Institute for Studies on Diabetes Foundation Inc. (ISDF) •Philippine Nurses Association (PNA) •Occupational Health Nurses Association of the Philippines (OHNAP) •Food and Nutrition Research Institute (FNRI) •Nutritionist-Dietitian Association of the Philippines (NDAP) Learn to access drug info on your cellphone. Send PPD to 2600 for Globe/Smart/Sun users. 143 Hypertension CONTENTS The Task Force................................................................................................................ Contents........................................................................................................................... Foreword.......................................................................................................................... Introduction....................................................................................................................... Statements of Recommendations I. How should blood pressure be measured? . ......................................................... II. How should hypertension be diagnosed?.............................................................. III. How should hypertension be worked up?.............................................................. IV. What advice should be given to hypertensive patients regarding lifestyle modification?............................................................................................. V. How should hypertension be treated?.................................................................... VI. How should hypertension be managed in special populations?............................. VII. How can hypertension be prevented among normotensives?............................... References....................................................................................................................... 144 143 144 145 147 147 147 148 149 150 150 151 152 Hypertension FOREWORD The Board of Trustees of the Philippine Society of Hypertension and all those who contributed to the realization of the Guidelines express their sincere appreciation to all who joined us in our efforts to control the hypertension epidemic in our country. The convenors of the multisectoral task force were composed of representatives mainly from the Philippine Society of Hypertension as well as the major subspecialty societies that had hypertension as one of their primary field of interest. They have worked long and hard to evaluate the evidence, decided on the practicalities of the recommendations and matched these with the best practices of the Filipino physicians. The contents of this document centered on the simplification of our threshold for diagnosis and treatment of hypertension at 140/90 mmHg and this is the major reason why this document is also called the 140/90 Report. The initial organization was in 2008 and the report was completed a year later. Subsequently, the contents of this report have been presented in various fora, scientific meetings, conventions, lectures, consultations and discussions in order to elicit responses from as many stakeholders as possible. In the end, the recommendations may represent a truly Filipinized document for the detection, diagnosis, treatment and follow-up of hypertension whose utilization will cut across various sectors of the medical profession. This document has the format of a report but hopefully will have the spirit of a guideline. Nelson S. Abelardo, MD Head Multisectoral Task Force www.TheFilipinoDoctor.com l Sign up and open your clinic to the world. 145 Hypertension INTRODUCTION The Philippine Society of Hypertension (PSH) recognizes that about 16.4% of the adult Filipino population (NNHeS 2003) have hypertension.1 This represents roughly 50% of total population of 84 million Filipinos. Only 75% of this group are aware of the problem and only about 65% of them are getting advice and treatment. However, among those who are being treated, only about 23% will have acceptable blood pressure control.2 Thus, 4.4 million adults can potentially benefit from monitored management. This number represents a considerable proportion of the productive sector of the country. The PSH came up with a clinical guideline on hypertension in 1996. However, due to recent developments with landmark trials and ground-breaking researches, as well as consideration of the practical aspects for adherence to the guidelines, the PSH found the need to update the present guidelines. Thus, the multi-sectoral task force for the Control of Hypertension was convened by the Philippine Society of Hypertension last January 12, 2008 at the Club Filipino, Greenhills, Mandaluyong City based on the need to update local guidelines on the detection and management of hypertension. The group recognized the need to simplify the guidelines to make them easier to comply with especially for the broad segment of our medical practitioners. Based on the results of focused group discussions, the participants of the 2008 meeting updated the statements put forth in the 1996 guidelines. This document discusses in detail the statements adapted during that meeting. I.How should blood pressure be measured? A.APPARATUS FOR BLOOD PRESSURE MEASUREMENT 1. The standard method for blood pressure mea surement is the use of indirect sphygmoma nometry. The most accurate and reliable technique is the auscultatory method using a mercury manometer.3,4 2. The Department of Health of the Republic of the Philippines issued a memorandum in year 2009 that all mercury manometers are to be banned from clinical use due to the toxic effects of mercury.5 3. In the absence of a mercury manometer, aneroid6 digital and other self – monitoring devices may provide acceptable alternatives, provided they have passed technical requirements for accuracy and are calibrated or checked regularly. The PSH conducts validation studies of non-mercurial types of sphygmomanometers for the purpose of certifying the accuracy and precision of commercially available models of blood pressure measurement devices. B.METHOD FOR INDIRECT MEASUREMENT OF BLOOD PRESSURE 1. A mercury manometer is ideal for accurate measurement. Aneroid, digital or other automated devices provide reasonable alternatives, provided that they satisfy technical requirements for accu- racy, and are calibrated and tested on a regular basis. 2. The manometer cuff should cover at least 2/3 of the length of the patient’s arm, while the bladder should cover at least 80% of the arm circumference. 3. The patient should be seated (or supine) with arms bared, supported, and at the heart level. He or she should have rested for at least 5 minutes, and should not have smoked or ingested caffeine within 30 minutes before measurement. 4. The edge of the cuff should be placed 1 inch above the elbow crease, with the bladder directly over brachial artery. 5. The bladder should be inflated to 30 mm Hg above the point of radial pulse extinction as determined by a preliminary palpatory determination. It should then be deflated at a rate of 2 mm Hg/beat, with the stethoscope bell placed directly overall the brachial artery. 6. Systolic pressure should be recorded at the appearance of the 1st clear tapping sound (Korotkoff phase 1). Diastolic blood pressure should be recorded at the disappearance of these sounds (Korotkoff phase V), unless these are still present near 0 mm Hg, in which case, softening of the sounds should be used as diastolic pressure (Korotkoff phase IV).7 7. For every visit, the mean of 2 readings, taken at least 2 minutes apart, should be regarded as the patient’s blood pressure. If the first 2 readings differ by 5 mm Hg or more, a 3rd reading should be included in the average. 8. If blood pressure is being taken for the first time, the procedure should be repeated with the other arm. Subsequent determinations should then be performed on the arm with a higher pressure reading. II.How should hypertension be diagnosed? A.STRATEGIES FOR DETECTION It is important that all Filipinos should know their blood pressure. By whatever method of detection, physicians and patients alike should realize that knowing their BP may result in early detection and treatment. General strategies for detection consist of: 1. Case Finding – Opportunities for case – finding abound in daily practice. Health practitioners from all fields should be encouraged to take BP measurements at each patient visit even if the patient consults for unrelated symptoms 2. Mass Screening – All should undergo mass screening such as industrial screening, examination of school based children and screening of family members.8 B.DEFINITION OF HYPERTENSION There are as many definitions of hypertension as there are potential investigators or committees. Roughly, the definition of hypertension should be that level of blood pressure where cardiovascular risk begins to rise. By convention, the Joint National Learn to access drug info on your cellphone. Send PPD to 2600 for Globe/Smart/Sun users. 147 Hypertension Committee for the Detection, Diagnosis, Treatment and Follow-Up of Hypertension (JNC VII)9 or the European Society of Cardiology-European Society of Hypertension (ESC-ESH)10 consensus guidelines are used as standard references for definition of hypertension but individual countries or even academic/research institutions may adopt some modifications. Table 2. Manifestations of Target – Organ Damage Table 1. Definition of Hypertension Systolic BP Diastolic BP Measurements done in at least 2 visits taken at least 1 week apart ≥140 mm Hg ≥90 mm Hg Seen in the first visit but with evidence of target organ damage. The multisectoral group decided to simplify the definition of hypertension to reflect the threshold with which clinicians would be alerted and be ready to institute pharmacologic management (Table 1). Hypertension is defined as sustained systolic BP elevation of 140 mm Hg or more, OR sustained diastolic BP elevation of 90 mm Hg or more, based on measurements done during at least 2 visits taken at least 1 week apart or hypertension in one visit but with evidence of target organ damage. Manifestations Cardiac Clinical, electrocardiographic or radio logic evidence of coronary artery disease Left ventricular hypertrophy by electro cardiography of echocardiography Left ventricular dysfunction or cardiac failure Cerebrovascular Transient ischemic attack or stroke Peripheral vascular Absence of one or more major pulses in the exteremities (except the dorsalis pedis) with or without intermittent claudi cation; arterial aneurysms Conditions ≥140 mm Hg ≥90 mm Hg Organ system Renal Serum creatinine >130 umol/ L (1.5 mg/dL) Proteinuria (1 + or greater) Microalbuminuria (300 mcg) Ophthalmologic Retinal arteriolar attenuation Hemorrhages &/or exudates, with or without papilledema/optic nerve edema 1. A detailed history and physical examination should be done in all patients with hypertension. Aspects of the history and PE which should be emphasized are summarized below. Items to emphasize in the clinical history and physical examination of hypertensive patients: Circumstances where hypertension is suspected: Clinical History 1. White coat hypertension is defined as BP elevation in the clinic setting but repeatedly normal out of the office.11 2. Isolated systolic hypertension is defined as systolic blood pressure of 140 mm Hg or more and a diastolic pressure of less than 90 mm Hg. 3. Masked hypertension is defined as a clinical condition in which a patient's office blood pressure (BP) level is <140/90 mm Hg but ambulatory or home12 BP readings are in the hypertensive range.13 III. How should hypertension be worked up? A.OBJECTIVES OF WORK-UP The objectives of a thorough hypertension work-up include the following: 1. To determine the etiology whether hypertension is primary or secondary; 2. To determine the presence of target organ damage (Table 2); 3. To detect and treat other risk factors for cardiovascular disease (Table 3); and 4. To determine the most appropriate form of management. With these objectives in mind, physicians should pay close attention to all aspects of the clinical evaluation, including extraction of a detailed history, performance of a thorough physical examination, and requisition of relevant laboratory tests. 148 a. Previous symptoms of cardiovascular, cerebro vascular, pulmonary, or renal disease, diabetes mellitus, gout, or dyslipidemia; b. Family history of hypertension, premature cardio vascular death, stroke, diabetes mellitus, or dyslipidemia; c. Personal and social history of smoking or tobacco use, occupational or domestic stress, substance abuse, psychosocial stress; d. Usual BP range with and without medication; e. Medications tried for hypertension, including response and adverse effects; f. Other medications being taken which may affect BP or response to treatment (e.g., contraceptives, steroids, NSAIDs, decongestants, appetite suppressants, immunosuppresants (cyclosporine), erythropoietin, beta-agonists, anti-depressants and MAO-inhibitors. g. Elicit history of intake of certain herbals and supplements that may contain substances which may raise blood pressure. Table 3. Risk Factors for Cardiovascular Disease Modifiable factors Non-modifiable factors smoking age hypertension male sex dyslipidemia family history of diabetes mellitus premature CAD obesity physical inactivity Hypertension Physical Examination Table 4. Clinical Clues to Secondary Causes of Hypertension a. Height and weight measurement, waist-hip ratio, body mass index Clinical clues Suspected condition Abdominal or flank masses, family history of adult polycystic kidney polycystic kidney Abdominal bruits, especially if a diastolic component is present renovascular disease Truncal obesity with purple striae Cushing’s syndrome Tachycardia, tremor, orthostatic hypotension, sweating, flushing and pallor pheochromocytoma Anemia, edema, azotemia, casts chronic kidney disease Pulse deficit, unequal pulses Takayasu’s arteritis, coarctation of the aorta b. Head and Neck – funduscopic examination, examination of the neck for bruits, distended veins or thyroid enlargement; c. Chest and Lungs – examination of the heart for heart rate; point of maximal impulse, apex beat, heaves, clicks, murmurs, arrhythmias, gallops; examination of the lungs. d. Abdomen – examination of the abdomen for truncal obesity; purple striae, bruits, enlarged kidneys, masses, and abnormal aortic pulsation; e. Examination of the extremities for diminished or absent peripheral arterial pulsations, bruits and edema; arm BP discrepancies greater than 10 mm Hg or when indicated, similar discrepancies between leg BPs; examination for presence of postural hypotension in the elderly, i.e., decrease in BP greater than 10 mm Hg on assumption of upright position from recumbent position; f. Neurologic assessment for stroke residuals or encephalopathy. 2. The following tests should be routinely performed in newly diagnosed hypertensives: a. fasting plasma glucose b. serum creatinine c. serum potassium d. urinalysis 3. The following examinations may be performed particularly only if there are specific indications: Cramps, body malaise, hypokalemia hyperaldosteronism a. ECG b. Chest X-ray c. Determination of lipid profile d. Uric acid e. Hematocrit f. Test for microalbuminuria 4. 2D echocardiography is not required for the routine evaluation of all hypertensive patients. Use is recommended to patients in whom anatomic or functional abnormalities are suspected. 5. Ambulatory BP monitoring is not routinely required for the work-up of all hypertensive patients except for white coat hypertension, resistant hypertension and masked hypertension.14,15 6. Confirmatory tests for secondary hypertension should be performed when clinical clues to their existence are present. Physical findings which should lead to the suspicion of these rare conditions are summarized below (Table 4): Use of contraceptive pills contraceptive-induced HPN Neck mass with bruit, lid lag, tremors; With or without exophthalmos thyrotoxicosis Poor BP control with drug therapy any of the above Sudden onset of hypertension any of the above Sudden deterioration of BP control any of the above IV.What advice should be given to hypertensive patients regarding lifestyle modification? A.CESSATION OF SMOKING All smokers should stop smoking. Several cohort and case-control studies provide unquestionable proof of the hazards of smoking. As a recognized risk factor for the development of coronary artery disease, smoking aggravates this risk in hypertensive patients.16 B.WEIGHT REDUCTION 1. Overweight patients (excess of >10% of ideal body weight, with a waist hip ratio of ≥0.9 in males and ≥0.8 in females and an abdominal circumference of ≥90 cm in males and ≥80 cm in females should attempt weight reduction at a rate of 1.0 lb or 0.5 kg per week. 2. Weight reduction can be achieved by total caloric reduction and regular aerobic activities (see item 3). Caloric reduction can be achieved through dietary prescriptions from a nutritionist. However, in the absence of a professional nutritionist, patients can be advised to decrease their total caloric intake by 15%. C.Regular physical activity Hypertensive patients should engage in regular aerobic physical activity unless contraindicated. This may be achieved by lower extremity aerobic exercise such as brisk walking, jogging or cycling for 30-60 minutes 3-4 times per week. www.TheFilipinoDoctor.com l Sign up and open your clinic to the world. 149 Hypertension D.Moderation of alcohol intake Table 5. Summary of Pharmacologic Recommendations Alcohol drinkers should moderate their consumption. A reasonable limit would be 30 cc (1 oz or 28 grams) of ethanol per day (equivalent to 60 cc or 2 jiggers of 100-proof whiskey, 240 cc or 2 wine glasses, or 720 cc or 2 bottles of beer). For people who have never been initiated to alcohol, it is prudent not to start drinking.17 Compelling Indication E.Optimization of dietary intake Adopt the Dietary Approaches to Stop Hypertension (DASH)18 eating plan (cite) which is a diet rich in fruits, vegetables and low fat dairy products with a lower content of dietary cholesterol as well as saturated and total fat. F.Moderation of salt intake Moderation of dietary sodium to 100 mmol/day (2.3 g Na or 5 g NaCI) may be attempted in all hypertensive subjects to see if this can lead to significant BP reduction. However, such restriction is absolutely necessary among patients with chronic kidney disease and congestive heart failure.19,20,21 G.Miscellaneous There are no good studies to justify recommend ations regarding relaxation and biofeedback nor an increase in dietary K, Ca, or Mg. V. How should hypertension be treated? The goal of treatment is to normalize BP and to reduce the increased risk of future cardiovascular events. The following recommendations suggest priority therapeutic options, depending on the underlying circumstances (Table 5). The initial choice of antihypertensive agent should be directed towards the most probable pathophysiologic abnormality or presence of compelling indications. Monotherapy is recommended as an initial option to control blood pressure but if the patient has co-morbid conditions and / or target organ damage, it is prudent to start combination therapy to achieve goal BP. Another consideration which may affect drug select ion is patient compliance. In some situations, this may take precedence over the given recommendations. When this becomes a problem, maneuvers to improve compliance may take into consideration the following 1) the drug’s dosing schedule, 2) cost, 3) side effects profile of drugs, and 4) an individual’s preference for a particular regimen. Lastly, patients’ education must include the need for maintenance medications despite normalization of blood pressure as well as regular follow-ups. 150 Medication Outcome Uncomplicated Any Reduction in: Hypertension a.stroke incidence by 35-40% (average) b. Myocardial Infarction by 20-25% c.Heart Failure by >50% Sustained reduction of 1 2mmHg in SBP for over 10 years will prevent 1 death for every 11 patients treated. Hypertension Beta blocker, Reduction in mortality and + Ischemic ACE inhibitor coronary events Syndrome Hypertension All except + Heart Failure CCBs Reduction in total mortality and coronary events Hypertension ACE inhibitor Achieve a target BP≤130/80 + Diabetes or an ARB Reduction in: Mellitus a.diabetes related mortality by 15% b.MI by 11% c.Microvascular complications of retinopathy and nephro- pathy by 13% d.Improves CVD outcome esp. stroke Hypertension + CKD with >1 gm albuminuria ACE inhibitor Achieve target BP ≤125/70 or an ARB in Slows progression of CKD combination with a loop diuretic Hypertension + Acute Stroke See Stroke Society of the Philippines Guidelines (cite) USE with CAUTION the following DRUGS Peripheral Beta-blockers May exacerbate symptoms Vascular of the disease Disease COPD and Beta-blockers May exacerbate or precipitate Bronchial symptoms of the disease asthma NB In the choice of medications, the clinician should take into account efficacy, tolerability and economics. The use of generic drugs should be guided by bioavailability and bioequivalence studies. Uncomplicated Hypertension 1. For all stages of hypertension, lifestyle modification is recommended. 2. For all hypertensive patients, pharmacologic treatment is indicated. 3. In uncomplicated hypertension, any of the five classes of anti-hypertensive drugs (diuretics, ACE inhibitors, ARBs, beta-blockers and calcium channel blockers) are recommended as the initial for monotherapy. VI.How should hypertension be managed in special populations? A.Hypertension in the elderly and very elderly In hypertensive elderly patients, low dose thiazide diuretics and calcium channel blockers are the preferred agents. Beta-blockers may be used as Hypertension alternative agents. In the very elderly up to the age 85 years, treatment and control of hypertension is associated with clinical benefits.22,23,24,25 B.Hypertension in pregnancy For pregnant patients with pre existing mild to moderate BP elevations, the value of continued use of anti-hypertensive medications continues to be controversial. These women are at low risk for cardiovascular complications within the short time frame of pregnancy with good maternal and neonatal outcomes and a reduction in blood pressure may impair uteroplacental perfusion and thereby jeopar dize fetal development. It is therefore recommended that drug treatment be started when SBP ≥150 or DBP ≥95 mm Hg for patients with pre-existing hypertension. It is important to differentiate hypertension that is chronic or pregnancy-induced (Table 6). A lower threshold BP of 140/90 mm Hg is indicated for women with gestational hypertension with or without proteinuria, pre-existing hypertension with superimposition of gestational hypertension or hypertension with subclinical organ damage or symptoms at any time during pregnancy. In pregnant patients with mild or moderate hypertension, treatment can be started using oral medications. Alpha methyldopa alone is ineffective, so betablockers provide a second option. When these two drugs fail, calcium antagonists such as nifedipine provide a third option. 1. In pregnant patients with SBP ≥170 or DBP ≥110 mmHg, this is considered an emergency requiring hospitalization. IV labetalol, oral methyl dopa26 or oral nifedipine may be given. Intravenous hydralazine should no longer be considered because its use is associated with more perinatal adverse effects compared to other drugs. 2. Calcium supplementation, fish oil supplementation and low dose aspirin have failed to consistently prevent the incidence of gestational hypertension and is therefore not recommended. However, low dose aspirin is used prophylactically in women who have a history of early onset (<28 weeks) pre-eclampsia. Table 6. Differences between Pregnancy-induced Hypertension and Chronic Hypertension Parameter Age Pregnancy-Induced Chronic Usually younger Usually older (<30 y.o.) (>30 y.o.) Parity Usually primigravid Usually multigravid Onset After 2 weeks AOG Before 20 weeks AOG Weight gain & edema sudden gradual Systolic BP <160 mm Hg >160 mm Hg Funduscopic Spasma, edema findings AV nicking, exudates Proteinuria present absent Plasma uric acid elevated normal Eclampsia (seizures) possible possible BP after delivery normal elevated AOG - age of gestation, AV – arteriovenous C.Hypertension in Emergency and Urgent Situations Hypertension may be complicated by acute life – threatening conditions such as those listed in table below. In such settings, there is a need for immediate blood pressure reduction. The agents that can be used for rapid control of hypertension are listed in subsequent tables below (Tables 7 and 8). Oral preparations are now available for the emer gency control of hypertension. These include capto pril, and clonidine However, these drugs do not provide good control of the rate of blood pressure reduction, a disadvantage blamed for numerous reports of unexpected myocardial or cerebral hypo perfusion. Thus, the parenteral agents listed in the table are preferred, specifically because of a more controlled rate of reduction of blood pressure In very severe hypertension uncomplicated by situations listed above, oral antihypertensive agents should be given and control of blood pressure should be achieved within 3 days. D.Current status of herbal preparations No indigenous herbal preparations have been adequately tested. Previous studies on sambong and garlic failed to demonstrate a significant effect on blood pressure.27 Table 7. Hypertension and Target Organ Disease Organ System Not Acutely Life-threatening Acutely Life-threatening Cardiac Left ventricular Acute coronary events hypertrophy (acute myocardial Coronary infarction, unstable angina) atherosclerosis Acute LV failure Pulmonary congestion or edema Cerebro- Transient Intracranial hemorrhage vascular ischemic attack Thrombotic stroke Hypertensive encephalopathy Peripheral Peripheral vascular occlusive disease Dissecting aneurysms Renal Malignat nephrosclerosis nephrosclerosis Ophthalmic retinopathy Papilledema / optic nerve head edema LV – left ventricle VII. How can hypertension be prevented among normotensives? Weight reduction among overweight individuals through moderate physical activity and reduced total caloric intake can decrease the incidence of hypertension. A significant risk reduction in the incidence of hypertension was demonstrated among normotensives subjected to weight reduction. Two trials reported odds ratios of 0.77 and 0.66 respectively. The weight reduction program involved a moderate increase in physical activity by brisk walking for 45 minutes 4-5 times a week as well as reduction in total caloric intake.28,29 Learn to access drug info on your cellphone. Send PPD to 2600 for Globe/Smart/Sun users. 151 Hypertension Table 8. Drugs for the Treatment of Hypertensive Crisis Drugs* Dose** Onset of Action (min) Adverse Reactions Special Indications PARENTERAL DRUGS - Vasodilators Nicardipine HCl 10-15 mg/h IV 5-10 Tachycardia, headache, flushing, local phlebitis Nitroglycerine 5-100 ug/min IV 2-5 Headache, vomiting, infusion methemoglobinemia Hydralazine HCl 10-120 mg IV 10 Acute heart failure Caution with coronary ischemia Acute LV failure, acute coronary insufficiency, post-operative (esp. coronary bypass) hypertension Tachycardia, headache, Eclampsia, body burns, malignant vomiting, aggravation of hypertension, post-operative angina pectoris, fluid retention hypertension Sodium 0.3-10 ug/kg/min IV instantaneous Nausea, vomiting, muscle Hypertensive encephalopathy, nitroprusside infusion, max dose twitching, methemoglobinemia, acute intracranial hemorrhage, for no more than cyanide toxicity, hypotension acute cerebral infarction, acute LV 10 min failure, acute coronary insufficiency dissecting aneurysm, catecholamine crisis, head injury, extensive body burns, malignant hypertension PARENTERAL DRUGS – Adrenergic Inhibitors Methyldopa 25-500 mg IV infusion 30-60 drowsiness Captopril 25 mg PO, repeat as 15-30 required Hypotension, renal failure in bilateral renal artery stenosis Clonidine 0.1-0.2 mg PO, 30-60 repeated every hour as required to a total dose of 0.6 mg Hypotension, drowsiness, dry mouth Eclampsia, perioperative hypertension ORAL DRUGS * Drugs such as Diazoxide, Phentolamine mesylate, Trimethaphan camsylate, and Labetalol hydrochloride are also for hypertensive emergencies but are not available locally. ** IV indicates intravenous; IM intramuscular, PO per orem References: 1. Velandria FV, Duante CA, Abille ET and Tangco JBM. The National Nutrition and Health Survey (NNHeS 2003-2004). Food and Nutrition Research Institute of the Department of Science and Technology (FNRI-DOST). 2. Sison J, Arceo L, Trinidad E et al. PRESYON 2: Report of the Council on Hyoertension. Philippine Heart Association Annual Convention, May 2007. 3. American Society of Hypertension. Recommendations for routine blood pressure measurement by indirect cuff sphygmomanometry. Am J Hypertens 1992;5:207-209 4. Frohlich, ED, Grim C, Labarthe DR, et al. Recommendations for human blood pressure determinations by sphygmomanometers: report of a special task force appointed by the steering committee, American Heart Association. Hypertension 1988;11:209A-222A. 5. Banatin CA, Go MV, Peñafiel RM and Bituin RA (eds.) Safe Hospitals in Emergencies and Disasters: Philippine Indicators. Administrative Order No. 2008 - 0021 – Gradual Phase-out of Mercury in all Philippine Health Care Facilities and Institutions. Department of Health, Republic of the Philippines, 2009 6. Canzanello VJ, Jensen PL, Schwartz GL. Are aneroid sphygmomanometers accurate in hospital and clinic settings? Ann Intern Med 2001;161:729-31 7. Veterans Administration Cooperative Study Group on Anti-hypertensive agents. Effects of treatment on mortality in hypertension: Results in patients with diastolic BP averaging 90 through 114 mmHg. JAMA 1970; 213:1143-52. 8. Littenburg B, Garber AM, Soc HC. Screening for Hypertension. Ann Intern Med 1990;122:192 9. JNC VII. The Seventh Report of the Joint National Committee on the Detection, Evaluation and Treatment of High Blood Pressure. 2004 10. ESC-ESH Guidelines for the Management of Arterial Hypertension. Journal of Hypertension 2007. 11. Mancia G, Zanchetti A. White coat hypertension misnomers, misconceptions and misunderstandings. What should we do next? J Hypertens 1996, 14:1049-1052 12. Gerin W, Schwartz AR, Schwartz JE, Pickering JE, Davidson KW, Bress J, et al. Limitation of current validation protocols for home blood pressure monitors for individual patients. Blood Press Monit ;2002 7:313-8 13. Pickering TG, Davidson, K, Gerin, W. Schwartz, JE. Masked Hypertension. Hypertension. 2002;40:795 14. Appel LJ, Stason WB. Ambulatory blood pressure monitoring and blood pressure self measurement in the diagnosis and management of hypertension. Ann Intern Med 1993:118:867-882 152 15. Sheps GS, Pickering TG, White WB, et al. Ambulatory Blood Pressure Monitoring (ACC Position Statement). JACC 1994; 23:1511-1513. 16. Pooling Project Research Group. Relationship of blood pressure, serum cholesterol, smoking habit, relative weight, ECG abnormalities to incidence of major coronary events: Final Report of the Pooling Project. J Chron Dis 1978;31:201. 17. World Hypertension League. Measuring your Blood Pressure. November 2003. http://www.mco.edu/org/whl/bloodpre.html 18. Blumenthal JA, Babyak MA, Hinderliter A et al. Effects of the DASH Diet Alone and in Combination With Exercise and Weight Loss on Blood Pressure and Cardiovascular Biomarkers in Men and Women With High Blood Pressure. Arch Intern Med.2010;170(2):126-135. ENCORE (Exercise and Nutrition interventions for CardiOvasculaR hEalth) study. 19. Kaplan NM. Moderate sodium restriction. Am J Hypertens 1990; 3:518-519. 20. Cutler JA, Follman D, Elliot P, Suh I. An overview of randomized trials of sodium reduction and blood pressure Hypertension 1997; 17 (Suppl 7): 1-27 -1-33. 21. Law MR, Frost CD, Wald NJ. By how much does dietary salt reduction lower blood pressure? III: analysis of data from trials of salt reduction. BMJ 1991;302:879-824. 22. Coope J, Warrender TS. Randomized trial of treatment of hypertension in the elderly in primary care. Br Med J. 1986; 293:1145-51. 23. Beard K, Bulpitt C, Mascie-Taylor H, et al. Management of elderly patients with sustained hypertension BMJ 1992;304:412-416. 24. Thijs L. Fagard R, Lijnen, et al. Why is antihypertensive drug therapy needed in elderly patients with systodiastolic hypertension? J Hvpertens Suppl 199l;12 (6):s25-s34 25. Insua JT, Sacks HS, Tai-Shing et al. Drug treatment of hypertension in the elderly: a meta-analysis. Ann lntem Med 1991; 121(5):355-362. 26. Collins R, Duley L. Methvldopa-based therapy in the treatment of preeclampsia in Pregnancy & Childbirth Module (eds Enkin MW, Keirse MJNC, Renfrew MJ, Neilson JP), Cochrane Database of Systematic Reviews": Review No. 03997, 29 JuIy 1992. published thru "Cochrane Updates on Disk", Oxford: Update Software, Spring, 1993. 27. Silagv CA, Neil HAW. A meta-analysis of the effects of garlic on blood pressure. JHvpertens 1991;12: 463-468. 28. Wassertheil-Smoller S, Blaurfox MD, Oberman AS, et al. The trial of antihypertnsive interventions and management (TAIM) study: adequate weight loss alone and combined with drug therapy in the treatment of mild hypertension. Arch Int Med 1992; 152: 131-136 29. Schotte DE, Stunkard AJ. The effects of weight reduction on blood pressure in 301 obese patients. Arch Intern Med. 1990; 150: 1701-1704. Hypertension Index of Drugs Mentioned in the Guideline This index is not part of the guideline. It lists the products and/or their therapeutic classes as mentioned in the guideline. For the doctor's convenience, brands available in the PPD references are listed under each of the classes. For drug information, refer to PPD, PPD Pocket Version, PPD Text, PPD Tabs, and www.TheFilipinoDoctor.com. CARDIOVASCULAR DRUGS Antiplatelet Agents Aspirin Aspilets Aspilets-EC Bayer Aspirin 100 mg Bayer Aspirin 300 mg Bayprin EC Cor - 30 Cortal Rhea Aspirin Antihypertensives ACE Inhibitors Benazepril HCl Cibacen Captopril Captril RiteMED Captopril Cilazapril Vascace Cilazapril/Hydrochlorothiazide Vascace Plus Enalapril Acebitor Hypace Naprilate Pharex Enalapril Renitec Enalapril/Hydrochlorothiazide Co-Hypace Co-Renitec Fosinopril BP Norm Imidapril Norten Vascor Imidapril/Hydrochlorothiazide Norplus Vascoride Lisinopril Zestril Lisinopril/Hydrochlorothiazide Zestoretic Moexipril Univasc Moexipril/Hydrochlorothiazide Uniretic Perindopril Coversyl Perindopril/Amlodipine Besilate Coveram Perindopril erbumine Perigard - 2/4 Perindopril/Indapamide Bi-Preterax Coversyl Plus Preterax Quinapril Accupril Quinapril/Hydrochlorothiazide Accuzide Ramipril Ramipro Tritace Winthrop Ramipril Ramipril/Felodipine Triapin Ramipril/Hydrochlorothiazide Alpha Blocker Phentolamine mesylate Angiotensin Receptor Blockers Azilsartan medoxomil Edarbi Candesartan Blopress Candez Candesartan/ Hydrochlorothiazide Blopress Plus Candez Plus Eprosartan Teveten Eprosartan/Hydrochlorothiazide Teveten Plus Irbesartan Aprovel Winthrop Irbesartan Irbesartan/Hydrochlorothiazide CoAprovel Winthrop Irbesartan + Hydrochlorothiazide Losartan Actizar Amozar Angiocard Angisartan Anzar Arbloc Bepsar Besartan Biozaar Cozaar Doxar Ecozar Getzar Hartzar Hylos-50 Hypertan Hyperthree Lifezar Lipewin Losacar Losargard Losium Lozaris Lozart 100 Myotan Neosartan Normoten/Normoten 100 Pharex Losartan Potassium RiteMED Losartan Potassium Vivasartan Wilopres Winthrop Losartan Potassium Xartan Zarnat Zarpose Losartan/Amlodipine Cozaar XQ Tozam Losartan/Hydrochlorothiazide 2Zaris Anzaplus Artazide Combizar Co-Normoten/Co-Normoten DS Duosar Getzar Plus Hyzaar/Hyzaar DS Lipewin H Forte Losacar-H Losargard Plus Neosartan Plus Pharex Losartan Potassium + Hydrochlorothiazide Vivasartan Plus Wilopres Plus Winthrop Losartan Potassium + Hydrochlorothiazide Xartan Plus Zarnat Plus Olmesartan medoxomil Cresart Olmetec Olmezar Olmesartan medoxomil/Amlodipine Normetec Olmesartan medoxomil/ Hydrochlorothiazide Olmetec Plus Telmisartan Micardis Pritor Telmisartan/Amlodipine Twynsta Telmisartan/Hydrochlorothiazide Micardis Plus PritorPlus Valsartan Diovan Valsartan/Amlodipine besylate Exforge Valsartan/Amlodipine besylate/Hydrochlorothiazide Exforge HCT Valsartan/Hydrochlorothiazide Co-Diovan Beta blockers Atenolol Cardioten RiteMED Atenolol Tenormin Therabloc Velorin Atenolol/Chlorthalidone Betaxolol HCl Kerlone Bisoprolol Bisoprolol Sandoz Concore Bisoprolol fumarate/ Hydrochlorothiazide Ziac Carteolol Mikelan Carvedilol Betacard Learn to access drug info on your cellphone. Send PPD to 2600 for Globe/Smart/Sun users. 155 Hypertension Carvedilol Sandoz Carvibloc Carvid Dilatrend Karvidol 25 mg Karvidol 6.25 mg Karvil 6.25/12.5 Vasolexin Xicard Esmolol Labetalol HCl Metoprolol succinate Betazok Betazok 25 mg Cardiosel-OD Metoprolol tartrate Betaloc Cardiosel Cardiostat Metocare Neobloc Pharex Metoprolol RiteMED Metoprolol Valvexin Metoprolol/Felodipine Logimax Metoprolol/Hydrochlorothiazide Nebivolol HCl Nebicar Nebilet Toricard-5 Pindolol Pyndale Visken Pindolol/Clopamide Viskaldix Propranolol Inderal Timolol Calcium Antagonists Amlodipine besylate Actapin Aforbes Alodine Amaday Ambesyl Ambloc Amcal Amlocor Amlodac Amlodine Amlodipine Besilate Amlonex Amvasc BE Angivas Biovasc B-Press Calbloc Cardiaz Coram Corvex Dailyvasc Dilavasc Godipine Hartvasc Lodicor Lopicard Norvasc Omnivas Pharex Amlodipine Besylate Ritemed Amlodipine Sedipin Vasalat Wilomax Winthrop Amlodipine besilate 156 Amlodipine besylate/ Atorvastatin calcium Norvasc Protect Amlodipine besylate/ Hydrochlorothiazide Amvasc Plus Amlodipine besylate/Olmesartan medoxomil Normetec Amlodipine besylate/Valsartan Exforge Amlodipine besylate/Valsartan/Hydrochlorothiazide Exforge HCT S-Amlodipine Amlobes Asomex Barnidipine HCl Hypoca Benidipine HCl Coniel Diltiazem Dilzem/Dilzem SA/Dilzem OD/ Dilzem SR Felodipine Dilahex Dilofen ER Felop ER Tab Felostal-5 ER Plendil ER RiteMED Felodipine Versant XR Felodipine/Metorpolol Logimax Felodipine/ Ramipril Triapin Isradipine Lacidipine Lacipil Lercanidipine HCl Zanidip Manidipine Caldine Nicardipine Cardepine Nifedipine Adalat/Adalat Gitz/Adalat Retard Calcibloc Calcibloc OD Heblopin Nimodipine Nimotop Verapamil Isoptin/Isoptin SR Verapamil Sandoz Verapamil/Trandolapril Tarka/Tarka Forte Centrally-Acting Drugs Clonidine HCl Catapres Methyldopa Aldomet Dopamet Diuretics Carbonic Anhydrase Inhibitors Acetazolamide Loop Diuretics Bumetanide Burinex Furosemide Furolink Indiurex Lasix Osmotic Diuretics Mannitol Sahar Mannitol 20% Solution for IV Infusion Mannitol/Sorbitol Potassium-Sparing Diuretics Spironolactone Aldactone Spironolactone/Hydroflumethiazide Aldazide Thiazides & Thiazide-Like Diuretics Hydrochlorothizide Diuzid Hytaz Pharex Hydrochlorothiazide Indapamide Natrilix SR Vazamide SR Other Vasodilators Diazoxide Hydralazine HCl Sodium nitroprusside Trimethaphan camsylate Cardioactive Drugs Organic Nitrates/Nitrites Nitroglycerin Deponit NT 5/Deponit NT 10 Nitrostat Transderm-Nitro